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Levator Ani Syndrome
Rectal and/or pelvic pain due to chronically contracted pelvic muscles, often described as a dull ache or pressure high in the rectum, typically worse when sitting
Synonyms
- Levator spasm
- Puborectalis syndrome
- Chronic proctalgia
- Pelvic tension myalgia
- Levator syndrome
- Proctodynia
Incidence
Unknown
Prevalence
6.6% by survey
Predominant Sex and Age
Predominantly female, middle age (30 to 60)
Peak Incidence
Unknown
What are the risk factors of Levator Ani Syndrome?
Unknown, possibly increased risk after pelvic trauma or instrumentation/surgery, childbirth
Genetics
Unknown
Physical Findings & Clinical Presentation
- •Levator ani syndrome is primarily a diagnosis of exclusion. Most commonly presents as rectal and/or pelvic pain and may radiate to the thigh or gluteus, usually worse with sitting and relieved by standing, sometimes associated with constipation and tenesmus.
- •Rome IV criteria can help distinguish levator ani syndrome from other causes of chronic rectal and pelvic pain:
- 1.Chronic or recurrent rectal pain or aching
- 2.Episodes lasting 20 min or longer
- 3.Tenderness during traction on the puborectalis
- 4.Exclusion of other causes of rectal pain, such as inflammatory bowel disease, bowel ischemia, intramuscular abscess, anal fissure, hemorrhoids, prostatitis, coccygodynia, and major structural alterations of the pelvic floor
- 5.Criteria fulfilled for the last 3 mo with symptom onset at least 6 mo before diagnosis
What causes Levator Ani Syndrome?
Hypothesized to be secondary to spasm of the pelvic floor muscles and elevated anal resting pressures, alternatively hypothesized to be due to dyssynergic defecation
Differential Diagnosis
- •Proctalgia fugax
- •Unspecified anorectal pain
- •Chronic pelvic pain/chronic prostatitis syndrome
- •Inflammatory bowel disease
- •Intramuscular abscess
- •Anal fissure, hemorrhoids
- •Prostatitis
- •Coccygodynia and major structural alterations of the pelvic floor
Differentiation among the three anorectal pain disorders (levator ani syndrome, proctalgia fugax, and unspecified) can be confusing and is summarized in the below table.
There is a great deal of overlap in the conditions, which are distinguished by the duration of pain and presence of rectal tenderness.
- •Levator ani syndrome: Episodes last more than 20 min; presence of rectal tenderness between episodes
- •Proctalgia fugax: Episodes last less than 30 min; no rectal tenderness between episodes
- •Unspecified: Does not fit into the above categories
Dysesthetic Anogenital Pain Syndromes
From Bolognia J: Dermatology, ed 4, Philadelphia, 2018, Elsevier.
Syndrome | Clinical History |
---|---|
Levator ani syndrome | Brief intermittent burning pain or tenesmus of the rectal or perineal area; aggravated by sitting or elimination |
Proctalgia fugax | Sudden stabbing pain in the perirectal area; awakens patient from sleep |
Coccydynia | Intermittent or persistent pain, usually burning type, localized to the coccyx |
Male genital pain syndrome | Intermittent, continuous, or episodic pain during penetration, ejaculation, micturition, or exercise |
Koro syndrome | Psychogenic disorder characterized by acute anxiety, fear of death, and sensations that the genitalia are inwardly retracted and (variably) burning pain |
Workup
Often can be diagnosed by history and exam alone. Consider additional testing to exclude alternative diagnosis.
Laboratory TestS
Consider stool studies, abdominal labs if concerned about alternative diagnosis
Imaging Studies
- •Sigmoidoscopy/colonoscopy
- •Ultrasonography
- •CT/MRI if concerned about alternative diagnosis
How is Levator Ani Syndrome treated?
Acute General Treatment
Muscle relaxants, such as methocarbamol, diazepam, cyclobenzaprine, or tizanidine, may be used in combination with nonpharmacologic therapy.
Chronic Treatment
Same as acute
Complementary & Alternative Medicine
- •Electrogalvanic stimulation found to be inferior to the above combination treatment
- •Botulinum toxin injections into the levator ani muscles found to be similar to placebo injections
Disposition
Outpatient treatment
Referral
- •Biofeedback therapy
- •Behavioral counseling
- •Rehab, physical therapy
Pearls & Considerations
Given the nature of the syndrome and pain, patients may be hesitant to discuss their concerns. Furthermore, the nature of treatment therapies may discourage compliance.
What is the prognosis of Levator Ani Syndrome?
The prognosis for levator ani syndrome can vary widely from person to person based on several factors:
- Severity of Symptoms: The severity of symptoms can impact the prognosis. Some individuals experience milder symptoms that can be managed effectively, while others may have more persistent or severe discomfort.
- Treatment Approach: The choice of treatment and its effectiveness play a significant role in determining the prognosis. Treatment options for levator ani syndrome may include pelvic floor physical therapy, lifestyle modifications, dietary changes, stress management techniques, medications, and in some cases, botulinum toxin injections.
- Individual Response: Each person’s response to treatment can differ. Some individuals may experience significant relief from symptoms with conservative treatments, while others may require more extensive management strategies.
- Compliance with Treatment: Consistency and compliance with the recommended treatment plan can impact the overall prognosis. Following a healthcare provider’s advice, engaging in exercises, and making necessary lifestyle adjustments are important factors.
- Underlying Factors: Identifying and addressing any underlying contributing factors, such as stress, anxiety, or hormonal imbalances, can influence the prognosis.
- Patient Education: Education about the condition and strategies for managing symptoms can empower individuals to better manage and cope with their condition, which can positively affect the prognosis.
- Multidisciplinary Care: In some cases, a multidisciplinary approach involving various healthcare professionals, such as gastroenterologists, gynecologists, urologists, and pain specialists, may be necessary for comprehensive management.
- Psychosocial Factors: Emotional and psychological factors, including stress, anxiety, and depression, can impact the prognosis. Managing these aspects can contribute to improved outcomes.
Levator ani syndrome is generally considered a chronic condition, but many individuals can experience relief from their symptoms with appropriate management and lifestyle adjustments. While some individuals may have more persistent symptoms, others may find that their symptoms become less frequent and less severe over time.
It’s important for individuals with levator ani syndrome to work closely with their healthcare providers to develop a personalized treatment plan and to address any concerns or questions. A positive and proactive approach to managing the condition can contribute to an improved quality of life and better long-term outcomes.
Suggested Readings
- Bharucha A.E., Trabuco E.: Functional and chronic anorectal and pelvic pain disorders. Gastroenterol Clin N Am 2008; 37: pp. 685-696.
- Chiarioni G., et al.: Biofeedback is superior to electrogalvanic stimulation and massage for treatment of levator ani syndrome. Gastroenterology 2010; 138: pp. 1321-1329.
- Rao S.S.C., et al.: Anorectal disorders. Gastroenterology 2016; 150: pp. 1430-1442.
- Simren M., et al.: Update on Rome IV criteria for colorectal disorders: implications for clinical practice. Curr Gastroenterol Rep 2017; 19 (4): pp. 15.